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Acamprosate Naltrexone Disulfiram Topiramate Alcohol Withdrawal


									                                                                                              Treatment Options for Alcohol Use Disorder
                                                                                         Acamprosate                                                                                                                                                 Naltrexone                                                                                                                                                Disulfiram                                                                                                                                      Topiramate
                                                                                                                                                                                                                                                                               Pearls                                                                                                                                                                                                                                                                                                            Pearls
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Alcohol Withdrawal Syndrome

                                                                                                            Pearls                                                                                                          mu
                                                                                                                                                                                                                                                                                                                                                                                                                                   Pearls                                                                       Ca+

                                                                                                 Serves as “artif icial alcohol”; may                                                                                                                              Can be used f or patients who                                                                                                                       Disulf iram should not be given to                                                                                                                            May be usef ul f or patients who
                                                                                                 be less ef f ective in situations in                                                                                                                              have achieved abstinence, are                                                                                                                       a patient in a state of alcohol                                                                                                                               have achieved abstinence, are
                                                                                                 which the patient has not yet                           Alcohol either acts directly upon mu                                                                      trying to achieve abstinence, or                                                                                                                    intoxication or without the                                                                                             GABA                                  trying to achieve abstinence, or
                                                                                                 abstained; patients should                                                                                                                                        are trying to reduce heavy                    Alcohol is metabolized to acetaldehyde,                                                               patient’s f ull knowledge; the                                                                                                                                are trying to reduce heavy               Symptoms begin within a f ew hours of discontinuation and may
Acamprosate is a derivative of the                                                                                                                       opioid receptors or causes release of
                                                                                                 continue treatment even if relapse                                                                                                                                drinking; less ef f ective in patients        which in turn is metabolized by                                                                       patient should not take disulf iram       Like alcohol, topiramate both reduces                                                                               drinking; may be usef ul as an                           last a f ew days to a week
amino acid taurine and, like alcohol,                                                                                                                    endogenous opioids; in either case, the
                                                                                                 occurs but should disclose any                                                                                                                                    who are not abstinent at the time             aldehyde dehydrogenase. Disulf iram is                                                                f or at least 12 hours af ter drinking;   excitatory glutamate                                                                                                adjunct agent; side ef f ects
both reduces excitatory glutamate                                                                                                                        result is increased dopamine release
                                                                                                 new drinking; dosing schedule                                                                                                                                     of treatment initiation; adherence            an irreversible inhibitor of aldehyde                                                                 a reaction may occur f or up to 2         neurotransmission and enhances                                                                                      include sedation, nausea, and
neurotransmission and enhances                                                                                                                           to the nucleus accumbens. Naltrexone
                                                                                                 may af f ect adherence; generally                                                                                                                                 is greatly increased with the                 dehydrogenase, thereby blocking this                                                                  weeks af ter disulf iram is stopped;      inhibitory GABA neurotransmission. It                                                                               weight loss; can cause metabolic                              Outpatient Treatment
inhibitory GABA neurotransmission. In                                                                                                                    blocks mu opioid receptors, and thus
                                                                                                 well tolerated, with diarrhea as the                                                                                                                              injectable f ormulation; side                 second-stage metabolism. When                                                                         the patient should be advised not         is also a carbonic anhydrase inhibitor.                                                                             acidosis or kidney stones;
particular, it seems to block mGlu                                                                                                                       theoretically reduces the euphoria and
                                                                                                 most common side ef f ect; no                                                                                                                                     ef f ects include nausea, vomiting,           alcohol is consumed in a patient taking                                                               to consume any f ood or                                                                                                                                       adverse ef f ects may be dose                                   For patients with:
receptors and perhaps also NMDA                                                                                                                          high of drinking.
                                                                                                 known interactions with                                                                                                                                           and site reactions (injection); may           disulf iram, toxic levels of acetaldehyde                                                             beverages containing alcohol; the                                                                                                                             dependent                                 Mild to moderate AWS (tremor, elevated pulse rate and blood
receptors.                                                                                                                                                                                                                                                                                                       build up, which leads to f lushing,
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                pressure, sweating, agitation, nervousness, sleeplessness,
                                                                                                                                                                                                                                                                   be pref erred treatment if goal is

                                                                                                 psychotropic medications (not

                                                                                                                                                                                                                                                                                                                                                                                                                       patient should carry an
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Dosing and Use
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                                                                                                                                                                                                                                                                                                                 tachycardia, nausea, vomiting, and                                                                                                                                                                                                                                                                                              anxiety, and depression)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       ss                                     etc

                                                                                                 metabolized by hepatic enzymes;                                                                                                                                   reduced-risk drinking; can block

                                                                                                                                                                                                                                                                                                                                                                                                                       emergency card stating that s/he

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                                                                                                                                                                                                                                                                                                                 other symptoms.
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                                                                                                 does not inhibit/induce hepatic                                                                                                                                   ef f ects of opioid-containing
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                                                                                                                                                                                                                                                                                                                                                                                                                       is taking disulf iram; common side
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                                                                         Dosing and Use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Relief of immediate symptoms, prevention of complications,
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                                                                                                                                                        Formulations:                                                                                                                                                                                                                                                  dermatitis, and sedation; not             Tablets: 25 mg, 100 mg, 200 mg
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                and initiation of rehabilitation
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Sprinkle capsule: 15 mg, 25 mg

                                                                                                                                                        Tablets: 25 mg, 50 mg, 100 mg                                                                                                                                                                                                                                  recommended f or patients older
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Supportive care and repletion of nutrient, f luid, or mineral
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Formulations:                                                                                                                                           Oral solution: 12 mg/0.6 mL
                                                                                                                                                        Intramuscular: 380 mg/vial                                                                                                                                                                                                                                     severe pulmonary disease,                                                                                                                                                                                             def iciencies (especially vitamin B)
Tablet: 333 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                   Dosage Range:
                                                                                                                                                                                                                                                                                                                 Formulations:                                                                                         chronic renal f ailure, diabetes,                                                                                                                                                                                              Benzodiazepines
                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Up to 300 mg/day; requires slow
                                                                                                                                                        Dosage Range:                                                                                                                                            Tablet: 250 mg, 500 mg                                                                                                                                                                                                                                                                                        Alternative options may include carbamazepine, valproate, or
Dosage Range:                                                                                                                                                                                                                                                                                                                                                                                                          peripheral neuropathy, seizures,          upward titration to reduce side ef f ects
                                                                                                                                                        Oral: 50 mg/day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   topiramate
666 mg 3 times daily (>60 kg)                                                                        Special Populations                                                                                                                                                                                                                                                                                               cirrhosis, or portal hypertension
                                                                                                                                                        Injection: 380 mg every 4 weeks                                                                                  Special Populations                     Dosage Range:                                                                                                                                                                                                                                                           Special Populations
666 mg 2 times daily (<60 kg)                                                                                                                                                                                                                                                                                                                                                                                                                                    Approved For:
                                                                                                                                                        Approved For:                                                                                                                                            250–500 mg/day, one-year duration                                                                                                               Multiple seizure disorders; migraine
                                                                                                 Saf ety and ef f icacy have not                        Alcohol dependence                                                                                                                                                                                                                                                                                       prophylaxis                                                                                                                                                                        Inpatient Treatment
                                                                                                                                                                                                                                                                    Saf ety and ef f icacy have not                                                                                                                         Special Populations                                                                                                                                       Approved f or use in children age
                                                                                                 been established                                       Blockade of effects of exogenously                                                                                                                       Approved For:                                                                                                                                   Not approved f or alcohol use disorder
Approved For:                                                                                                                                                                                                                                                       been established                             Maintenance of alcohol                                                                                                                                                                                                                                               2 and older f or treatment of                                For patients with:
                                                                                                                                                        administered opioids (oral only)
Maintenance of alcohol                                                                           Pregnancy risk category C (some                                                                                                                                                                                 abstinence                                                                                            Saf ety and ef f icacy have not                                                                                                                                seizures; clearance is increased           Severe AWS (hallucinations, delirium tremens, psychotic
abstinence                                                                                       animal studies show adverse                                                                                                                                       Pregnancy risk category C (some                                                                                                                     been established                                                                                                                                               in pediatric patients                                    symptoms, and seizures)
                                                                                                 ef f ects; no controlled studies in                                                                                      Side Effects and Safety                  animal studies show adverse                                                                                                                                                                                                                                             Side Effects and Safety                                                                           Extremely high alcohol intake
                                                                                                 humans)                                                                                                                                                           ef f ects; no controlled studies in                                                                                    Side Effects and Safety                                                                                                                                                                                                                         Signif icant psychiatric symptoms
                                                                                                                                                                                                                                                                                                                                                                                                                       Pregnancy risk category C (some                                                                                                                                Pregnancy risk category C (some
                                                                 Side Effects and Safety                                                                                                                                                                                                                                                                                                                               animal studies show adverse                                                                                                                                    animal studies show adverse
                                                                                                                                                                                                                                                                                                                                                                                                                       ef f ects; no controlled studies in                                                                                                                            ef f ects; no controlled studies in
                                                                                                 Limited available data in patients                                                                                                                                 Limited available data in patients
                                                                                                                                                                                                                                                                                                                                                                                                                       humans)                                                                                                                                                        humans)
                                                                                                 with cardiac impairment                                                                                                                                            with cardiac impairment

                                                                                                                                                                                                                                                                    Dose adjustment not generally
                                                                                                 For moderate renal impairment,                                                                          Eosinophilic pneumonia,                                    necessary f or mild renal
                                                                                                                                                                                                                                                                                                                                                                                                                       Contraindicated in patients with
                                                                                                                                                                                                                                                                                                                                                                                                                       severe cardiovascular disease
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Use with caution in patients with
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      cardiac impairment                      Psychosocial + Pharmacologic
                                                                                                                                                                                                         hepatocellular injury (at excessive                        impairment; not studied in
                                                                                                 recommended dose is 333 mg
                                                                                                                                                                                                         doses), severe injection site                              moderate to severe impairment                                                                                                                                                                                                                        Metabolic acidosis, kidney stones,
                                                                                                 three times daily;                                                                                                                                                                                                                                                      Myocardial inf arction, congestive                                                                                                                                                                           Lower dose by half f or patients
                                                                                                                                                                                                         reactions requiring surgery                                                                                                                                                                                                                                                                                     secondary narrow-angle closure
                                                                                                 contraindicated in severe                                                                                                                                                                                                                                               heart f ailure, respiratory                   Not recommended f or patients                                                                                                                                  with renal impairment
                                                                                                                                                                                                                                                                    Dose adjustment not generally                                                                                                                                                                                                                        glaucoma, oligohidrosis and
                                                                                                 impairment                                                                                               Do not use if patient: is taking                                                                                                                               depression, hepatotoxicity                    with chronic renal f ailure
                                                                                                                                                                                                                                                                    necessary f or mild hepatic                                                                                                                                                                                                                          hyperthermia (more common in
                                                 Suicidal ideation and behavior                                                                                                                           opioid analgesics, is currently                           impairment; not studied in severe                                                                    Contraindicated in patients taking                                                                                                              children), rare activation of suicidal                       Use with caution in patients with
                                                                                                                                                                                                          dependent on opioids or is in                             hepatic impairment;                                                                                                                                                                                                                                  ideation and behavior
                                                                                                 Dose adjustment not generally                                                                                                                                                                                                                                           metronidazole, amprenavir,                    Not recommended f or patients                                                                                                                                  hepatic impairment
                                                                                                                                                                                                          acute opiate withdrawal, has                              contraindicated in acute hepatitis
                                                                                                 necessary f or patients with                                                                                                                                                                                                                                            ritonavir, or sertraline, and in              with hepatic insuf f iciency or
                                                 Do not use if patient has severe                                                                                                                         f ailed the naloxone challenge, or                        or liver f ailure                                                                                    those with psychosis or                                                                                                                          No absolute contraindications
                                                 renal impairment                                hepatic impairment                                                                                       has a positive urine screen f or                                                                                                                                                                             cirrhosis
                                                                                                                                                                                                                                                                                                                                                                         cardiovascular disease                                                                                                                           other than allergy to topiramate
                                                                                                                                                                                                          opioids                                                                                                                                                                                                                                                                                                                                                                                                                              Pharmacotherapy is good f or:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Patients with active alcohol dependence
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Patients who have stopped drinking but have cravings or slips
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Patients who have previously f ailed to respond to psychosocial
                                                                                Motivational Enhancement Therapy                                                                                                                                                             Cognitive Behavioral Therapy                                                                                                                                           12-Step Facilitation and 12-Step Fellowships                                                                                                                                                        approaches

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Psychotherapeutic or psychosocial approaches can:
                                                                                                                   Motivational interviewing is patient-f ocused                                                                                                                                                                                                                                                                                                                                                                                            Twelve-Step Facilitation (TSF) consists of a structured,
                                                                                                                   counseling with the direct goal of enhancing one’s                                                                                                                                                                                                                                                                                                                                                                                       manual-driven approach to f acilitating early recovery f rom
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increase motivation f or abstinence
                                                                                                                   motivation to change by helping explore and                                                                                                                                                                                                                                                                                                                                                                                              alcohol abuse/alcoholism and other drug abuse/addiction.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Improve motivation f or medication adherence
                                                                                                                   resolve ambivalence (e.g., “I want to stop drinking,                                                                                                                                     Cognitive behavioral therapy (CBT) is based on the                                                                                                                                                                                              Its purpose is to help patients accept their need to abstain
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Improve overall outcomes
                                                                                                                   but I’m af raid I’ll be awkward in social situations”).                                                                                                                                  premise that our behaviors stem f rom our thoughts                                                                                                                                                                                              and to actively participate in 12-step f ellowships (such as
                                                                                                                   Although it was originally developed to help                                                                                            Joe’s                                                                                                                                                                                                                                                                                            Alcoholics Anonymous, or AA) as a means of maintaining
                                                                                                                                                                                                                                                                   Bar                                      and belief s, and theref ore that negative thoughts

                                                                                     0                             individuals with problem drinking, it can be used in                                                                                                                                     can lead to maladaptive behavior. CBT is                                                                                                                                                                                                        abstinence. It is intended to be implemented on an
                                                                                                                   the treatment of patients with other f orms of                                                                                                                                           designed to modify the behaviors and                                                                                                                                                                                                            individual basis in 12 to 15 sessions and is based in the 12
                                                                                                                   substance abuse and dependence. With                                                                                                                                                     thoughts/belief s that contribute to substance abuse                                                                                                                                                                                            steps and traditions of AA.
                                                                                                                   motivational interviewing the clinician is a f acilitator,                                                                                                                               and dependence. CBT helps patients identif y
                                                                                                                   helping the patient identif y, articulate, and resolve                                                                                                                                   triggers f or substance use, such as particular                                                                                                                                                                                                 Although mutual support groups such as 12-step
                                                                                                                   his or her own ambivalence without direct                                                                                                                                                people or places or even emotions, and helps them                                                                                                                                                                                               f ellowships can be very benef icial in helping patients with
                                                                                                                   persuasion, conf rontation, or coercion.                                                                                                                                                 develop techniques to avoid those triggers or, if                                                                                                                                                                                               substance use disorder, these programs are based on the
                                                                                                                                                                                                                                                                                                            unavoidable, to cope with them.                                                                                                                                                                                                                 premise that addiction is an illness in which those af f licted
                                                                                                                   Motivational enhancement therapy (MET) is an                                                                                                                                                                                                                                                                                                                                                                                             are unable to control their use of the drug. As such, they
                                                                                                                   adaptation of motivational interviewing in which the                                                                                                                                                                                                                                                                                                                                                                                     typically require complete abstinence as the goal. This may
                                                                                                                   therapist uses f eedback to strengthen the patient’s                                                                                                                                                                                                                                                                                                                                                                                     theref ore pose conf lict f or patients with alcohol use
                                                                                                                   own motivation and commitment to change.                                                                                                                                                                                                                                                                                                                                                                                                 disorder who are attempting reduced-risk drinking.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Presented at the 2011 NEI Global Psychopharmacology Congress.

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